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At risk for alcohol use disorder (any pt in general medical/mental health care setting)
Screen all pts periodically for unhealthy alcohol use [S]; if no AUD, but screen(+) for unhealthy use, provide single brief intervention [W]. - For screening, use either the 3-item AUDIT-C1 or the single-item SASQ.2
- If screen(+) for unhealthy use (AUDIT-C score ≥5 or (+) SASQ score), provide an initial, single brief intervention3 [W].
Recommended limits for alcohol consumption: - Men ≤65 yo: ≤4 standard drinks/day or ≤14/wk
- Men >65 yo or women of any age: ≤3 standard drinks/day or ≤7/wk
Footnotes 1 AUDIT-C (Alcohol Use Disorders Identification Test – Consumption) asks 3 questions:
1) How often did you have a drink containing alcohol in the past yr?
2) On days in the past yr when you drank alcohol, how many drinks did you typically drink?
3) How often did you have ≥6 drinks (for men) or ≥4 drinks (for women) on an occasion in the past yr?
Points are scored w/ a minimum score of 0 (for nondrinkers) and max possible score of 12. Consider a screen (+) for unhealthy alcohol use if AUDIT-C score is ≥5 points.
2 SASQ (Single-Item Alcohol Screening Questionnaire) asks 2 questions:
1) Do you sometimes drink beer, wine, or other alcoholic beverages?
2) How many times in the past yr have you had:
• Men: ≥5 drinks in a day?
• Women: ≥4 drinks in a day?
A (+) screen is any report of drinking ≥5 drinks (men) or ≥4 drinks (women) on an occasion in the past yr.
3 Brief intervention overview:
1) Express concern
2) Advise (abstain or decr drinking)
3) Provide feedback linking alcohol use and health
4) Offer referral to addiction tx if appropriate
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S/P screening: Alcohol use disorder suspected/confirmed
Does not require immediate stabilization for withdrawal Provide appropriate intervention, determine tx setting, treat w/ psychosocial and pharmacotherapy interventions. - Educate on AUD, health consequences, and tx options.
- If mod-severe AUD, naltrexone oral1/injectable2 or topiramate3,4 recommended [S]; acamprosate5 or disulfiram6 suggested [W].
- If 1st-line tx contraindicated or ineffective, consider gabapentin4,7 [W].
- Not recommended: baclofen, buspirone, citalopram, fluoxetine, quetiapine.
- Monitor adherence, tx response, and adverse effects.
- Offer 1 or more psychosocial interventions8 to pts w/ AUD; consider pt preference and availability [W].
- Promote active involvement in group mutual help programs9 for pts in early recovery or following relapse; consider pt preference and availability [S].
- Coordinate evidence-based, addiction-focused psychosocial/psychopharmacologic intervention(s) to address concurrent biopsychosocial problems, consistent w/ pt priorities.
Footnotes 1 Naltrexone Oral [S]
• Indications: AUD (at least 2-4 days of pre-tx abstinence not required but recommended for improved response)
• Baseline eval: ALT/AST, urine β-hCG (females), urine drug screen to confirm no opioid use
• Warnings/cautions: hepatotoxicity, mod-severe renal impairment, vulnerability to opioid OD on d/c, diminished effects of opioid-containing meds; insufficient evidence in pregnancy
• Dose: 50 mg PO qd; alternatively, 25 mg PO qd or bid w/ meals to reduce nausea, esp during wk 1; or 100 mg PO qod or 150 mg PO q3 days
2 Naltrexone Injectable [S]
• Indications: AUD (at least 2-4 days of pre-tx abstinence not required but recommended for improved response)
• Baseline eval: ALT/AST, pt has adequate muscle mass for injection, urine β-hCG (females), urine drug screen to confirm no opioid use
• Warnings/cautions: hepatotoxicity, mod-severe renal impairment, injection site rxns, depression/suicidal thoughts, vulnerability to opioid OD on d/c, diminished effects of opioid-containing meds; insufficient evidence in pregnancy; use IM injections w/ caution if thrombocytopenia or coagulation disorders
• Dose: 380 mg IM q4wk or qmo as gluteal injection
• Consider when medication adherence is of concern and pt accepts tx w/ monthly injections by clinician
3 Topiramate [S]
• Indication: AUD (pre-tx abstinence not required but may improve response)
• Baseline eval: renal fxn, serum bicarbonate, urine β-hCG (females)
• Warnings: Do not abruptly d/c tx; instead, taper dose gradually; cognitive dysfxn, psychiatric disturbances, and sedation may occur; acute myopia and secondary angle closure glaucoma; oligohydrosis and hyperthermia; metabolic acidosis; incr risk of suicidal ideation; use during pregnancy can cause cleft lip/palate
• Dose: Initiate at 50 mg PO qd and titrate up gradually over several wks (to minimize side effects) to a max dose of 100 mg PO bid
• Special populations: CrCl <70 mL/min: Administer 50% dose and titrate more slowly; dose adjustment may be required in hepatic impairment
4 Not FDA labeled for AUD tx.
5 Acamprosate [W]
• Indication: AUD
• Baseline eval: CrCl (estimated or measured), urine β-hCG (females)
• Warning: Insufficient evidence in pregnancy
• Dose: 666 mg PO tid; 333 mg PO tid if CrCl 30-50 mL/min; contraindicated if CrCl ≤30 mL/min
• Good tx option for pts taking prescribed opioids or w/ significant hepatic damage/impairment
6 Disulfiram [W]
• Indications: AUD w/ abstinence >12h and BAL=0, consents to tx/appreciates risks, goal is total alcohol abstinence
• Baseline eval: ALT/AST, CBC and serum chemistries, physical/psychiatric assessment, ECG if hx of cardiac dz, verify abstinence w/ breath or BAL, urine β-hCG (females)
• Warning w/ alcohol-disulfiram rxn: Avoid alcohol in all forms, including mouthwash, OTC products
• Other warnings: severe renal/hepatic impairment, cerebrovascular dz or cerebral damage, nephritis, epilepsy, hypothyroidism, DM; safety in pregnancy not established
• Dose: 250-500 mg PO qd x1-2wk, then 250 mg PO qd (range: 125-500 mg qd); reduce dose to 125 mg to decr side effects; for monitored administration, consider 500 mg PO on Mon/Wed/Fri
• Best suited for pts who have made an informed choice for this tx type, are highly compliant, and are under medical supervision
7 Gabapentin [W]
• Indication: AUD (at least 2-4 days of pre-tx abstinence not required but recommended for improved response)
• Baseline eval: CrCl (estimated or measured), urine β-hCG (females)
• Warnings: Do not abruptly d/c tx; instead, taper dosage gradually; may cause CNS depression including somnolence/dizziness; anaphylaxis and angioedema; incr risk of suicidal ideation; use during pregnancy may incr risks of preterm birth, NICU admission, and small size for gestational age
• Dose: Initiate at 300 mg PO on day 1 and titrate up gradually (to minimize side effects) by 300 mg daily, as tolerated, to target dose of 1800 mg/day in 3 divided doses
• Special populations: Adjust dose for renal fxn; when CrCl <60 mL/min, consider target dose <1800 mg/day
• Good tx option for pts w/ co-occurring neuropathic pain, some pts w/ sleep disorders, or pts w/ clinically significant hepatic dz
8 Psychosocial interventions include behavioral couples therapy, cognitive behavioral therapy, community reinforcement approach, motivational enhancement therapy, and 12-step facilitation.
9 Approaches to encourage mutual help group involvement include peer linkage, network support, and 12-step facilitation.
Requires immediate medical/mental health stabilization for withdrawal Use standardized measures to assess withdrawal severity; determine appropriate setting for mgmt; treat w/ BZDs (in most cases) as either predetermined, fixed-tapering schedule or sx-triggered tx. - Assess withdrawal severity using clinical judgment and standardized measure (e.g., CIWA-Ar).1
- If hx of DTs/withdrawal seizures, inability to tolerate PO meds, concomitant medical conditions, severe withdrawal (CIWA-Ar ≥20), or risk of withdrawal from other substances (e.g., sedative hypnotics): In-pt medically supervised withdrawal mgmt strongly supported by expert consensus.
- If moderate withdrawal (CIWA-Ar ≥10) and any of: recurrent failures at ambulatory withdrawal, unlikely to complete ambulatory withdrawal (e.g., due to homelessness), active psychosis/severe cognitive impairment: In-pt medically supervised withdrawal mgmt strongly supported by expert consensus.
- For mod-severe withdrawal: Use BZD w/ adequate monitoring [S]. Use either predetermined, fixed-tapering schedule (w/ additional medication prn) or sx-triggered tx (med given only when s/sx of withdrawal).
- If mild-mod withdrawal and risks of BZDs outweigh benefits:2 Consider carbamazepine, gabapentin, or valproic acid [W].
Footnotes 1 Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar): A 10-item scale used to assess and diagnose the severity of alcohol withdrawal; score <8-10=mild withdrawal; score 8-15=moderate withdrawal; score ≥15=severe withdrawal.
2 Examples of risks: inadequate monitoring available, abuse liability, allergy/adverse rxns.
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